Guest Columns

Compliance: A game of follow the leader

Steven Littlehale
Steven Littlehale

Follow the leader. Do you remember playing this game when we were kids? The rules then were easy: Follow the person in front of you and try to do exactly what he or she did. There really were no rules — you followed the leader and did your best. Compliance today is a bit like playing follow the leader.

The preeminent leader to follow in compliance is the Office of Inspector General, whose mission is to protect the integrity of the Department of Health & Human Services programs, as well as the health and welfare of program beneficiaries. 

While the Accountable Care Act requires all skilled nursing facilities to have an effective compliance program in place now, we are still awaiting formal rule making. However, much guidance for SNF providers already exists, including the OIG's 7 Elements of an Effective Compliance Program for Nursing Facilities first published in 2000, as well as the supplemental guidance from 2008.

Corporate Integrity Agreements and OIG annual work plans highlight the areas that should be included in a provider's auditing and monitoring program. OIG negotiates CIAs with providers as part of the settlement of investigations arising under a variety of civil false claims statutes. CIAs posted on the OIG website clearly show their expectations related to provider compliance, with a focus on quality of care and the medical necessity of therapy services.

A quick scan of the annual work plan identifies OIG areas of focus that should be areas of focus for your organization as well. The emphasis on data and dashboards give us clues as to what might be forthcoming in the regulations; something to mimic in your own operations, and as best as you can – follow the leader. 

What is the OIG monitoring for SNFs in its fiscal 2015 work plan?  Medicare Part A billing! Why? Prior OIG work found that SNFs increasingly billed for the highest level of therapy, even though beneficiary characteristics remained largely unchanged. Sound like a medical necessity question? In a recent PointRight study, we found that 52.5% of RUG scores were billed at the RU level in fourth quarter of 2014 — up from 50.4% in Q4 of 2013. Follow the leader, and build into your compliance program a review of your therapy services, as well as RUG patterns and trends, to ensure that the services and intensity provided meet the medical necessity criteria.

CMS also provides tools that may shape your compliance plan. The newly released 2015 PEPPER reports aggregate state, jurisdiction and national data to show providers how they compare to others in target areas.  Are there target areas where your organization is an outlier? Building your monitoring and auditing program elements around your outliers is a great start. In addition, consider building in systems to monitor and audit areas where RAC auditors are probing, MAC review areas, and any areas of past noncompliance in your organization.

By following the example of compliance leaders around you, you will march on to success — and soon you will find your organization setting the pace for others!

Steven Littlehale is a gerontological clinical nurse specialist, and executive vice president and chief clinical officer at PointRight Inc.

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